Keeping an eye on the general practice nurse (GPN) forums on social media has highlighted the uncertainty regarding what medications GPNs can and cannot give, and the legal and professional landscape around what GPNs can or cannot do remains unresolved for many. This is not just an issue for newly qualified nurses (NQNs) entering the profession but also for experienced and well-established GPNs negotiating the ever-changing landscape of practice. Students also tell me this is a problem. Both pre- and post-registration students report a lack of clarity regarding what needs to be in place to be able to safely administer medications in general practice. Every cohort mentions this, along with an array of stories regarding different practices they have observed. Just when I think I have heard it all, I hear another example where GPNs have, with the best intentions, exposed themselves to the risk of professional scrutiny and even prosecution in some cases. Professional guidance and the legislation exists, but there is difficulty in synthesising this and interpreting some of the ambiguous or difficult language. This article hopes to bring some clarity and help GPNs navigate this topic.
Reflection
The problem does not seem to exist in hospital settings
This will sound remarkably familiar to lots of readers. When I first qualified as a nurse in the 1990s I remember, quite vividly, that it was drilled into me throughout 3 years of education, that as a registered nurse, I could not give any medication that had not been written up. What did my tutors mean by written up? Well, in a hospital setting this was quite easy to conceptualise. If it was not correctly written on the paper drug chart at the end of the bed, it was not given. Easy! I would not take telephone instructions to give medications or fluids, I would not do this on say so, I would only administer a drug or bag of fluids if the doctor (nurse prescribing was not a thing then) had written it up or prescribed it. Not only that, the ‘prescription’ had to be accurate. I was militant about checking before I gave anything. Does it have a date? Does it have a signature? Is the dose, route and frequency specified? The only time I ever deviated from this was in an emergency where the risk of doing nothing was greater than the risk of giving a medication which was not correctly written up. I knew where I stood; it was clear. I also felt confident and empowered to decline to give something unless the correct ‘prescription’ was in place. This confidence and clarity soon dissipated when I left the hospital ward and joined general practice.
What is different about general practice?
So, what was different in general practice and why did I struggle with this? There was no longer a senior nurse or a nursing team to go to for advice. I had GPs who were supportive and kind, but did not understand my professional regulations or what I could or could not do. Furthermore, the GPs were keen to give me increased responsibility to make decisions and I was keen to accept this. They believed in me and my capabilities, I was flattered and did not question what was within my professional boundaries. Finally, I wanted to please my employers, and this was a new dynamic; the GPs were responsible for my career progression now, I did not want to say no.
You don't know what you don't know
Reflecting on my early years as a GPN, I shudder at the thought of some of things I used to do, but that is the benefit of hindsight, further education and increased awareness. One of my favourite sayings is: ‘you don't know what you don't know’. And I clearly did not know that what I was doing was wrong. For example: I had undertaken the asthma and chronic obstructive pulmonary disease (COPD) diploma modules, as they were in those days, and so I thought I had expert knowledge to be able to advise on, start and make changes to inhaled therapies. I enjoyed the responsibility; I liked that my employers trusted me and were happy for me to extend my practice. The GPs left me to it. They saw me as the expert, and I was in terms of asthma and COPD, but I was not an expert in prescribing. I had received no further training regarding prescribing, but the GPs just signed everything I printed off. I thought it must be ok because they are signing it and the law clearly states that responsibility is with the person signing the prescription. If I assessed a person and felt they needed antibiotics for their chest, I would add a prescription, based on the COPD protocol (thinking the protocol would protect me), and send it for signing by a GP.
B12 injections were always interesting as we were instructed by our practice manager to give it and then find the old expired acute prescription on the computer system, reissue the prescription, print it off and send it for signing. I had no idea why we needed to do this. I did not question it, I just did it and so did the other nurses; we were blissfully ignorant and, most importantly, our employers were pleased with us. It was many years later when I was teaching in a university myself and students started to raise concerns regarding what they had been advised in practice, that I started to explore the guidance and legislation around this. I will try and make it simple.
What does the law say?
The Human Medicines Regulation (2012) is clear: prescription only medicines can only be administered or supplied where one of the following three instructions is in place:
- A signed prescription
- A signed patient specific direction (PSD)
- A patient group direction (PGD).
There are some specific exemptions, one of which relates to the administration of adrenaline in an emergency, but for everything else, one of the above needs to be in place. I will deal with the first of these legal requirements in the following section.
What constitutes a signed prescription?
Exploring the term prescription is an interesting journey of discovery. I assumed for many years that a prescription in primary care was the green piece of paper (FP10) given to a patient signed by a GP (nowadays electronically generated and signed). In fact the law does not mention the colour of the paper or format of the prescription. There are a set of minimum requirements it must meet (Human Medicines Regulation, 2012), but if these are met, theoretically, it could be written on a beer mat or a piece of tissue paper. Interestingly, I remember a GP colleague sharing a story of writing a prescription on a scrappy piece of paper while on holiday as he did not have his prescribing pad with him. The local pharmacy did question the presentation of the prescription, but once satisfied it met the legal requirements, it was dispensed.
Due to this misunderstanding, if I were asked to administer a medicine for which I did not have a patient group direction (PGD) I would print off an FP10 and get a GP sign it, and I was then happy I had a prescription and I could give the medication. But was this ok? In more recent years I have questioned this practice. The Specialist Pharmacy Service (SPS) produced some guidance in 2018 where they stated that an FP10 was not to be confused with a prescription, as this was an instruction to supply from a pharmacy or dispensary. Therefore, I thought an FP10 is not an instruction to administer a medication, it is an instruction to dispense. This changed my practice and I started to insist a PSD was in place before I would give any medicine. I advised all my students of this and encouraged changes to working practices which recommended the presence of PSDs or PGDs before any medicine was given. Interestingly, the SPS updated this guidance in (2020) and removed the line about FP10s. What they say now is that prescription forms (FP10, TTO form) are examples of PSDs to supply medicines not administer them; therefore, my practice has remained unchanged.
More about patient specific directions (PSDs)
Put simply, there is more than one type of PSD. What is important to note is that before signing a PSD, the prescriber should assess the named patient on an individual basis (SPS, 2020). Some PSDs are for administration of medicines and some for supply. I will not detail the legal requirements of a PSD as this can be found easily in the resources listed in Further reading. In practice, a PSD is commonly referred to as a prescription by those who write and follow them because this indicates that it is written by a prescriber. So, most prescribing that takes place in general practice uses PSDs, you just may not have realised it. A further realisation was that the drug card at the end of the bed in hospital was also a PSD: it was an instruction to give a medication to a named person. Acknowledging this makes it so much easier to answer the question of ‘can I give it?’. Simply ask yourself, do I have a PSD or a PGD (which meets the legal requirements) to administer this medication? If the answer is no, then stop and think.
FP10s for claiming back purposes (personally administered items)
This area of prescribing practice can further add to the confusion GPNs experience, because an FP10 is produced and signed after the administration of some medicines. A personally administered item is classed as a prescription item, which is prescribed and administered by a member of the practice team and attracts payment under the ‘NHS General Medical Services Statement of Financial Entitlements’ (NHS, 2021). What this means is that there is a list of medicines that general practice can purchase directly from the supplier to dispense and administer to patients. B12 injections, some vaccines, local anaesthetics, and intrauterine devices are common examples of this. An FP10 is then produced and signed for the purpose of claiming back, or for high volume items, such as hepatitis A vaccines, a form known as the FP34 is completed and submitted to the NHS Business Services Authority (NHSBSA) for reimbursement. These are sometimes referred to as PPA claims. GP surgeries often do this due to the financial benefits associated. For example, the cost of buying B12 injections in bulk can be a lot less than the standard payment made to the practice per injection given, plus the practice can claim a dispensing fee. What is important here is to remember that the non-prescribing nurse will still require a PSD before the medication can be administered to the patient. Generating an FP10 is purely for financial reimbursement and can be generated by a prescription clerk or other admin staff for signing after the administration.
Patient group directions (PGDs)
Of course, some medicines, including most immunisations, are administered in practice under the terms and conditions of a PGD. What is important to remember about PGDs is that they must be fully read and signed before using them. It is important to carefully check that both you and your patient meet the terms and conditions listed; if either person is outside of these, then a PSD will be needed before administering the medication. The SPS (2020) highlight that where a PSD exists, there is no need for a PGD.
Starting new medications or reissuing expired medications
This is a difficult one and based on all that I have read and experienced I would advise against non-prescribing GPNs undertaking this. If you have decided to start a person on a new medication or reinstated an expired prescription under your own initiative, then this is prescribing, and you must ask yourself as a non-prescriber, do you have the skills, knowledge and competence to do this? In the absence of a recognised independent prescribing qualification, I would say the answer must be no. Yes, the person who signs the prescription is legally responsible for the prescription and will be the person called to answer in court, should something go wrong. But professionally it could be argued that you have acted outside of your scope of professional practice and in contravention of The Code (Nursing and Midwifery Council (NMC), 2018).
What does the NMC say about it?
In 2018, the NMC withdrew their guidance on Administration of Medicines and opted to follow the Royal Pharmaceutical Society (RPS) Competency Framework for all prescribers (RPS, 2021). The Code (NMC, 2018) clearly states in section 18.1 that only suitable qualified persons can prescribe, advise on, or provide medicines or treatment, including repeat prescriptions and only if you have enough knowledge of that person's health and are satisfied that the medicines or treatment serve that person's health needs. This is clear: only qualified persons can prescribe. What about those involved in administration of medicines?
Administration of medicines
The NMC highlight that before administering medications, you have a responsibility to ensure you are satisfied that the prescriber has followed the RPS competency framework, and that patient safety is not at risk (NMC, 2020). They go on to say that you should say no if you have any concerns that prescribing has not been carried out appropriately, you are being asked to work outside of The Code or patient safety is at risk.
For those of you who have not read or seen the RPS Competency Framework (2021), I recommend you look at this as a matter of urgency.
Revisiting the past and reflections
If we revisit some of the practices of the past, such as printing off B12 prescriptions after the dose has been given, we can clearly see that this should not happen. Before giving a B12 injection, a PSD needs to be in place. This is the case even if the product has been dispensed elsewhere and the patient brings it with them (CQC, 2022).
Non-prescribing nurses should not be adding new medications or making changes to patients’ prescriptions, neither should they reinstate expired medications, as they are not suitably qualified to do so. I am aware that GPs often send tasks or practice notes to GPNs to change or start medications, but in this instance, you need to consider your professional responsibilities and the audit trail. If you are making changes to medications, you are accountable for your practice. Therefore, it is much safer to request the prescriber makes the changes on a computer where they are logged in.
Dressings
The unrestricted availability of dressings in secondary care (fetching what you need and applying it) makes it difficult to understand why you need to work any differently in primary care. But you do. Where dressings are provided to patients by means of FP10 (not from central stores) then it can be tempting to think it is ok to add these to a prescription as they are low risk items, but the same principles apply. Unless you are a qualified prescriber, you should not be creating PSDs (remember an FP10 is an example of a PSD).
In summary
The person who signs the prescription remains legally responsible for it, but this does not detract the non-prescribing nurse from their professional responsibilities and a commitment to maintain patient safety. Before giving medicines in general practice, non-prescribing nurses need to stop and think: is this covered under a PGD, or do I need a PSD? Ask yourself ‘where is my authorisation to give this, and does that authorisation meet legal and professional requirements?’. Remember, the drug card at the end of the bed (and its electronic equivalent) is a PSD. Think about any experiences you may have had on the wards: you would not have administered any medication that was not written up correctly, so why would you now?
Conclusion
Patient safety should be the primary concern for all nurses when administering medicines, recognising that legislation and guidance exists to make the process safer. It is important for non-prescribing GPNs to understand the legal and professional frameworks which govern prescribing, as the legal responsibility of the signatory does not discharge the nurse from their professional responsibility to ensure that prescribing has adhered to legislation and guidance. The dynamics of being employed by GPs can create tension for nurses in terms of meeting the expectations of the employer while working within professional boundaries. However, The Code (NMC, 2018) can empower nurses to say no and raise concerns when required.
Key points
- GPNs need to ensure the correct authorisation is in place before administering medications to keep themselves and their patients safe
- GPNs should be empowered to say no and question a request which asks them to work outside of their professional scope
- Medicines management approaches are not transferable from secondary care to primary care, the landscape is different and GPNs need to understand it
FURTHER READING
- British Medical Association. Patient group and patient specific directions. 2020. https://www.bma.org.uk/advice-and-support/gp-practices/prescribing/patient-group-and-patient-specific-directions
- Gov.UK. Patient group directions (PGDs). 2022. https://www.gov.uk/government/publications/patient-group-directions-pgds
- Royal College of Nursing. Patient Specific Directions (PSDs) and Patient Group Directions (PGDs). 2022. https://www.rcn.org.uk/clinical-topics/Medicines-management/Patient-specific-directions-and-patient-group-directions
- Royal Pharmaceutical Society. A competency framework for all prescribers [online]. 2021. https://www.rpharms.com/resources/frameworks/prescribing-competency-framework/competency-framework
- Specialist Pharmacy Service. Questions about patient specific directions (PSD). 2020. https://www.sps.nhs.uk/articles/questions-about-patient-specific-directions-psd/
CPD REFLECTIVE PRACTICE
- Why does this issue exist in general practice? Why are so many general practice nurses unclear?
- How is the administration of medicines managed in your place of work? Could this be improved?
- Will you make any changes to your own professional practice after reading this?